Open ICU vs Closed ICU question for hospitalists/nocturnists

[cyrushanleone]

I have been looking at a lot of hospitalist/nocturnist jobs in my area (mostly semi-rural setting, 100-150 miles from nearest 500K+ population city) and have noticed that many of them are "no procedures, no codes/RRT, but open ICU".
I understand that primarily in open ICU, the hospitalist/nocturnist is the admitting physician while the intensivist is a consultant, while it is flipped around in closed ICU, but how do these specifics vary in hospitals? How involved are the intensivists in an open ICU? For the really sick patients, do they usually take complete control of the patient or are they still only giving recommendations? How much can you trust the "no procedures" bit if someone needs emergent line/intubation in the middle of the night in the ICU?

Know that this varies with the hospital, but was wondering what some of the experiences of some of the hospitalists/nocturnists here have been like. Would appreciate any input/info.

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[mszzeta]

I interviewed at these positions before and my personal thought is that as an internist, one should not choose these positions unless you are very comfortable with your clinical skills in managing very sick patients with very solid ICU training in your residency

 

[IMGASMD]

What year are you? What kind of residency are you doing? Meaning big academic vs community hospitals? How much do you want to do?

In short? There is not uniform answers for your questions. It’s all based on local practice pattern/culture.

Where I trained, we had 30 bed
combined sicu/micu. Overflow to CCU. Typically ccu attendings could careless about septic patients with multiple organ failures. So sometime MICU attendings will also have to round in CCU. Consultants would just come in and write whatever they want, sometimes without discussing with MICU attending. As you can see, it’s very chaotic.

I worked as a nocturnalist at a rural hospital, no procedures, run codes. Intubation and lines are placed by EM if they have time, which they usually would. Anything too difficult get transferred, sometimes from ER directly before even being admitted. Also you learn to use PIV for temporary measures, I don’t think I ever “had” to place a-line. Because like I said, anything too difficult gets kicked to bigger hospitals.

The answer probably isn’t what you’re looking for. But in short, it depends on the hospital.

 

[cyrushanleone]

What year are you? What kind of residency are you doing? Meaning big academic vs community hospitals? How much do you want to do?

In short? There is not uniform answers for your questions. It’s all based on local practice pattern/culture.

Where I trained, we had 30 bed
combined sicu/micu. Overflow to CCU. Typically ccu attendings could careless about septic patients with multiple organ failures. So sometime MICU attendings will also have to round in CCU. Consultants would just come in and write whatever they want, sometimes without discussing with MICU attending. As you can see, it’s very chaotic.

I worked as a nocturnalist at a rural hospital, no procedures, run codes. Intubation and lines are placed by EM if they have time, which they usually would. Anything too difficult get transferred, sometimes from ER directly before even being admitted. Also you learn to use PIV for temporary measures, I don’t think I ever “had” to place a-line. Because like I said, anything too difficult gets kicked to bigger hospitals.

The answer probably isn’t what you’re looking for. But in short, it depends on the hospital.

I'm a PGY3 in a community based hospital. Our hospital has a closed ICU, but I feel that our ICU training is fairly solid. Don't feel entirely comfortable with lines/intubations though.

When you were a nocturnist at the hospital, was there an intensivist on call/present or were you solely responsible for the ICU patients? I can see how managing through peripheral lines can be done short term if a line is really needed, but did you ever have a situation where an intubation was required and the physician responsible was late/not present? At one point in the patient's illness did you have to transfer a patient because the patient was too sick (shock requiring more than one pressor? ARDS?)

 

[IMGASMD]

You just hope that the patients either had the family conversations and on CMO or send them out earlier than that point.

I also worked with a lot of mid-levels, you sort of learn to practice at the bottom of your license. Because you don’t want anything happening when there is no MD in house.

We (IM) ran icu pretty much. Don’t really have back up. We had pulmonary but he’s definitely not CC trained, nor come in on the weekends.

Like I said it’s only for my shop, every shop can be different. Talk to your future colleagues about all these concerns before you take on a job that you don’t feel comfortable with.

 

[jdh71]

Most of these places you have a right of first refusal. Go look at them in the ED and if it looks over your head, you tell the ED, send them to the city. Done.

I’m a little disappointed IM grads leave without being comfortable with central lines but that is what it is. You should NOT be intubating anyway.

Often the ICU is really only needed because of the nursing care ratio if it’s just little old ladies on some norepi for a UTI and IM grad can do that.

Sniff around a bit and see if the job will let you triage based on comfort.

 

[MedicineZ0Z]

I interviewed at these positions before and my personal thought is that as an internist, one should not choose these positions unless you are very comfortable with your clinical skills in managing very sick patients with very solid ICU training in your residency

Are you aware that NPs/PAs routinely staff ICUs overnight?

I'm a PGY3 in a community based hospital. Our hospital has a closed ICU, but I feel that our ICU training is fairly solid. Don't feel entirely comfortable with lines/intubations though.

When you were a nocturnist at the hospital, was there an intensivist on call/present or were you solely responsible for the ICU patients? I can see how managing through peripheral lines can be done short term if a line is really needed, but did you ever have a situation where an intubation was required and the physician responsible was late/not present? At one point in the patient's illness did you have to transfer a patient because the patient was too sick (shock requiring more than one pressor? ARDS?)

You can run pressors PIV for enough time to transfer. Though I don't see why you can't place a central line, should be a skilled learned in residency.

And if a patient needs an airway, they aren't getting transferred without one. You can't transfer with an LMA unless in rare cases. You'd need a very strong anesthesia block, airways on other rotations, couple airway courses and proficiency with video laryngoscopy being your 1st line option. That puts you very well ahead of all non-physicians (paramedics, RTs, midlevels) who manage airways but not quite up to par with non-anesthesia physicians who manage them.
Now if it's a matter of bagging until someone else comes, can usually do that except - it would really suck to be that guy. Best to come in prepared to handle all aspects of the job.

 

[Trogghunter]

I have been looking at a lot of hospitalist/nocturnist jobs in my area (mostly semi-rural setting, 100-150 miles from nearest 500K+ population city) and have noticed that many of them are "no procedures, no codes/RRT, but open ICU".
I understand that primarily in open ICU, the hospitalist/nocturnist is the admitting physician while the intensivist is a consultant, while it is flipped around in closed ICU, but how do these specifics vary in hospitals? How involved are the intensivists in an open ICU? For the really sick patients, do they usually take complete control of the patient or are they still only giving recommendations? How much can you trust the "no procedures" bit if someone needs emergent line/intubation in the middle of the night in the ICU?

Know that this varies with the hospital, but was wondering what some of the experiences of some of the hospitalists/nocturnists here have been like. Would appreciate any input/info.

As long as there is an intensivist then you should trust that they'll handle the more complex issues that arise in house, and you should always have the ability to transfer out. Even if you need to transfer a patient but every hospital is on diversion, the intensivist should still be managing the vent/pressors/critical illness. Just make sure that you have the no code/rrt/procedure policy set in stone in your contract. I foresee the worst case scenario as a tanking patient, can't transfer, and intensivist is MIA. I don't believe that would be the norm or ever happen unless the intensivists stopped working, but that's not really your problem if your contract specifies the role that you describe. At my current job, we had an open ICU when I started and it was closed a year ago. We did our own procedures based on how comfortable we felt. Our previous MICU docs were not very involved and were not very good, but we had procedure support from surgery and anesthesia, and RT helped with vent settings (which is fine most of the time). I still moonlight at a hospital with an ICU but no intensivist support and I manage intubated people on a pressor or 2, but if the patient is not improving rapidly then they get transferred to where I work most of the time or to one of the level 1s in the region.

The intensivist availability will vary, believe that, but if your contract says no lines/procedures etc, then that means that in the middle of the night or 11:30am, someone is doing that line and it ain't you. Try to get a feel from the other hospitalists how the intensivists are, but remember that it varies person to person, and the group can always change.

 

[Meerkatology]

nocturnist here, I work both at a open icu hospital and a closed.

I don't feel things are too different for me, in the open icu , I can still consult the intensivist for things that I don't feel comfortable managing alone.

but I've only worked at a single place since finishing residency so im not sure if policies are same everywhere?
i'd say for open icu's as long as they always have an intensivist on call that can help you out prn , then its fine